Hee Chang Ahn

The transverse radial artery forearm flap.

Background: In an attempt to improve the versatility of the radial forearm flap, a new design was developed: the transverse radial artery forearm flap. Methods: The transverse radial artery forearm flap is designed elliptically in the distal palmar forearm with the long axis oriented transversely parallel to the wrist. The donor defect is closed by a V-shaped flap, which is elevated as a fasciocutaneous flap based on the ulnar artery by V-Y advancement. This second flap allows defect coverage without the need for a skin graft. From March of 1994 to February of 2005, the authors treated 39 patients with this flap. Free flaps were used in 36 patients and three patients were operated on with reverse pedicled flaps. Results: Twenty-five patients had head and neck defects, 11 patients had defects of the distal foot or great toe, and three patients had hand defects. In 13 cases, an osteocutaneous flap was elevated, and three flaps were transferred as sensate flaps. Maximum flap dimensions were 10 × 6 cm. The longest vascular pedicle in this series was 20 cm. All flaps survived. Except for two cases of delayed healing, no complications occurred at the donor site. Conclusions: The transverse radial artery forearm flap is more versatile than the conventional radial flap, with the additional advantage of a long vascular pedicle. Its design allows for harvest of a piece of radial bone, which is pedicled on a completely different portion of the radial artery than the skin paddle. Thus, the setting of the bony portion can be chosen liberally. Donor-site morbidity is reduced, and the result is aesthetically pleasing.

Delayed infection after a zygoma fracture fixation with absorbable plates.

A 48-year-old man who had received a bioresorbable plate fixation for a zygomatic bone fracture 13 months earlier visited our clinic complaining of sudden facial swelling. The facial computed tomographic scan showed the soft tissue swelling without any bony abnormality, and the symptoms did not improve after 1 week of antibacterial therapy. The patient had a diagnosis of a late infection caused by unresorbed plates, and exploratory surgery was performed. Partially resorbed plates and screws were seen, and we removed the remnants of such completely. The symptoms were relieved after the operation, and there was no recurrence during 8 months of follow-up.

A Revision Restoring Projection after Nipple Reconstruction by Burying Four Triangular Dermal Flaps

Background Numerous techniques have been used to achieve long-term projection of the nipple following nipple-areola reconstruction. However, the reconstructed nipple loses projection over time. We describe a technique that uses local flaps to improve the lost projection of reconstructed nipples. Methods Between November 2013 and March 2015, nine patients (11 nipples) underwent revisional nipple reconstruction for lost projection. Only C–H nipple reconstructions were included in this study. The medical history of each patient was reviewed and photographs were taken in front and lateral views. All patients attended routine follow-up visits. Deepithelialized triangular flaps were made on all four sides of the nipple and buried in the opposite corners in order to augment the volume of the nipple. Anchoring sutures were used to attach each triangular flap on the side opposite their point of origin, and the resulting defects were closed directly. Results This procedure was used successfully in nine patients (11 nipples). Adequate projection was achieved in all patients and no complications occurred. The average nipple height was 3 mm before operation, 7 mm one day after operation, 5 mm at the six-month follow-up, and 5 mm at the 12-month follow-up. The average nipple-areolar angle was 164° before the operation, 111° one day after the operation, 130° at the six-month follow-up, and 133° at the 12-month follow-up. Conclusions The method described provides a solution to the loss of projection in reconstructed nipples. We recommend this technique because it leads to better projection, greater volume, and a more natural shape.

Trends in digital replantation

Tremendous advances have been made in the field of digital replantation since its introduction a half century ago. The purpose of this article is to provide an overview about established techniques and new trends in the field of replantation and revascularization of amputated hands and digits. Controversial issues are discussed. Emphasis is placed on indications for replantation and revascularization.

Two-Step Incision for Periarterial Sympathectomy of the Hand

Background Surgical scars on the palmar surface of the hand may lead to functional and also aesthetic and psychological consequences. The objective of this study was to introduce a new incision technique for periarterial sympathectomy of the hand and to compare the results of the new two-step incision technique with those of a Koman incision by using an objective questionnaire. Methods A total of 40 patients (17 men and 23 women) with intractable Raynauds disease or syndrome underwent surgery in our hospital, conducted by a single surgeon, between January 2008 and January 2013. Patients who had undergone extended sympathectomy or vessel graft were excluded. Clinical evaluation of postoperative scars was performed in both groups one year after surgery using the patient and observer scar assessment scale (POSAS) and the Wake Forest University rating scale. Results The total patient score was 8.59 (range, 6-15) in the two-step incision group and 9.62 (range, 7-18) in the Koman incision group. A significant difference was found between the groups in the total PS score (P-value=0.034) but not in the total observer score. Our analysis found no significant difference in preoperative and postoperative Wake Forest University rating scale scores between the two-step and Koman incision groups. The time required for recovery prior to returning to work after surgery was shorter in the two-step incision group, with a mean of 29.48 days in the two-step incision group and 34.15 days in the Koman incision group (P=0.03). Conclusions Compared to the Koman incision, the new two-step incision technique provides better aesthetic results, similar symptom improvement, and a reduction in the recovery time required before returning to work. Furthermore, this incision allows the surgeon to access a wide surgical field and a sufficient exposure of anatomical structures.

Wire or Hook Traction for Reducing Zygomatic Fracture

Background Variable methods have been introduced for reduction of the zygomatic fractures. The Dingman elevator is used widely to reduce these fractures but is inappropriate in certain types of fractures which require atypical traction vectors. We introduce and examine an alternate method of reducing zygomatic fractures using wire and hook traction. Methods A retrospective study was performed for all zygomatic fracture patients admitted between 2008 and 2014. Medially rotated fractures were reduced by using a wire looped through an intermaxillary screw secured on the medial side of the zygoma. Laterally rotated fractures were reduced using a hook introduced through an infrazygomatic skin incision. Results No accidental bleeding or incomplete reduction was observed in any of the cases. Postoperative imaging demonstrated proper reduction immediately after the operation. Follow-up computed tomography study at 1 month after operation also demonstrated proper reduction and healthy union across the previous site of fracture. Conclusion The hook and wire method allowed precise application of traction forces across zygomatic fractures. The fractured bone fragment could be pulled in the direction precisely opposite to the vector of impact at the time of trauma. Soft tissue damage due to dissection was minimized. In particular, this method was effective in reducing rotated bone fragments and can be an alternative option to using the zygoma elevator.

Four extremity salvage with long vein grafts in Buerger’s disease

Buerger disease is a rare non-atherosclerotic inflammatory vascular disease involving the small and medium-sized arteries and veins of young smokers, and is more common in males [1,2]. The risk of major amputation remains high, with an overall amputation rate of 33% with conservative treatment [3]. We present the rare case of a 37-year-old male with a confirmed diagnosis of Buerger disease, who suffered from severe ischemic pain, cold intolerance, purple color change, and progressive peripheral necrosis in 4 limbs for 1 year. Arteriography of the 4 extremities revealed segmental obstruction of all major arteries below the elbow and knee level, and relatively well-maintained patency of the distal stump in both radial and posterior tibial arteries by collateral circulation. To resolve the ischemia of the 4 limbs, we performed reconstruction of 4 arteries with long vein grafts: radial artery reconstruction with a cephalic vein graft in both hands, and popliteal artery to posterior tibial artery bypass reconstruction with a lesser saphenous vein in both lower legs, in order. After surgery, we reevaluated the vascular status of the reconstructed vessels with follow-up angiography (Figs. 1−3). The ischemic problems in all extremities significantly improved without ischemic pain, except for right third toe tip necrosis, over a follow-up period of 5 years (Fig. 4). In Buerger disease, surgical revascularization has limitations due to the extensive vascular involvement characteristic of this condition, resulting in lower patency rates after surgery [1,2]. In this case of progressive 4-extremity ischemia in a young patient with segmental involvement in the main arteries, revascularization with long vein grafts was a very Im ages Fig. 1. Preoperative and postoperative brachial arteriography in the right upper limb. (A) Both radial and ulnar artery occlusion at the proximal forearm level (white arrows indicate both ends of segmental occlusion in the radial artery) and collateral flow of a hypertrophic interosseous artery were seen before surgery. After resection of the involved vessel, with surgical findings of inflammation and thrombosis, radial artery reconstruction was performed with a cephalic vein graft 16 cm in length that was harvested from the right forearm. (B) Radial artery patency was maintained with good blood flow at 1 year postoperatively (white arrows indicate both ends of the grafted vein). A B

Management of a Recurrent Ischial Sore Using a 3-Flap Technique

As the quality of rehabilitation has improved (e.g., through the increased use of wheelchairs), ischial sores have become one of the top 3 most common types of sores in terms of location, with an annually increasing number of patients [1]. Even after musculocutaneous or perforator flaps are performed to treat pressure sores, complications such as ulcer recurrence and wound dehiscence still remain common [2]. A 48-year-old man underwent surgery to treat a lumbar spinal cord tumor in 2003. In 2005, due to his bedridden state, he experienced a left ischial sore. In the same year, he was treated with bursectomy, a rotation flap, and a local flap. After a rehabilitation period that allowed him to ambulate and sit, the ischial sore recurred in 2017. After treating him with negative-pressure wound therapy, we performed a bursectomy, packed the dead space with a semitendinosus muscle flap that had no effect on the patient’s ambulatory ability, and covered the skin area with a local flap. However, after surgery, we observed abrasions and seroma in the ischial region (Fig. 1). To fix this problem, we performed a complete bursectomy, repositioned the semitendinosus muscle flap to apply more padding to the ischial tuberosity, packed the remaining dead space with an inferior gluteal artery pedicled adipofascial flap that did not involve muscle [3] to maintain the patient’s ambulatory ability, and covered the skin using a V-Y advancement flap (Figs. 2, 3). Considering the patient’s ambulatory ability and the shortage of tissue due to the recurrence of the sore, we believe the usage of the 3-flap technique presented above was an appropriate treatment (Fig. 4). Thus, we must consider each patient’s condition IMAGES

Surgical Management of Localized Scleroderma

Background Localized scleroderma is characterized by a thickening of the skin from excessive collagen deposits. It is not a fatal disease, but quality of life can be adversely affected due to changes in skin appearance, joint contractures, and, rarely, serious deformities of the face and extremities. We present six cases of localized scleroderma in face from our surgical practice. Methods We reviewed six localized scleroderma cases that were initially treated with medication and then received follow-up surgery between April 2003 and February 2015. Six patients had facial lesions. These cases presented with linear dermal sclerosis on the forehead, oval subcutaneous and dermal depression in the cheek. Results En coup de sabre (n=4), and oval-shaped lesion of the face (n=2) were successfully treated. Surgical methods included resection with or without Z-plasty (n=3), fat graft (n=1), dermofat graft (n=1), and adipofascial free flap (n=1). Deformities of the affected parts were surgically corrected without reoccurrence. Conclusion We retrospectively reviewed six cases of localized scleroderma that were successfully treated with surgery. And we propose an algorithm for selecting the best surgical approach for individual localized scleroderma cases. Although our cases were limited in number and long-term follow-up will be necessary, we suggest that surgical management should be considered as an option for treating scleroderma patients.